Contact info
- Phone
- 1-844-716-4663
- Fax
- 1-800-887-1338
Eligibility
- Patient must not have prescription coverage through any Private Insurance, State or Federal Program.
- Patient must meet program income guidelines which are based on the FPL.
- Co-pay assistance is also available.
- Income limit, single
- Not published
- Income limit, couple
- Not published
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- Yes
- US citizenship or residency required
- Yes
Not sure where your income falls? See this year's federal poverty guidelines (opens in a new tab).
Application process
- Documents to attach
- Proof of income
- Prescriber license number
- NPI number
- Both DEA and state license numbers
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Provider
Getting the medication
- Patient receives
- Medication
- Shipped to
- Provider
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- New application every 6 months
Medications covered
- Siklos (hydroxyurea)